Port-Site and Wound Recurrences in Cancer Surgery: Incidence - Pathogenesis - Prevention

150 Pages·2000·9.8 MB·English

by  Ph.D., A. Tannapfel, C. Wittekind (auth.), Marc A. Reymond M.D., H. Jaap Bonjer M.D., Ferdinand Köckerling M.D. (eds.)

M.A. Reymond· H.J. Bonjer· F. K6ckerling (Eds.)
Port-Site and Wound Recurrences in Cancer Surgery
Springer-V erlag Berlin Heidelberg GmbH
M.A. Reymond· H.J. Bonjer· F. Kockerling (Eds.)
Port-Site and Wound
Recurrences
in Cancer Surgery
lncidence - Pathogenesis - Prevention
Foreword by Sir Alfred Cuschieri
With 60 Figures and 20 Tables
Springer
Marc A. Reymond, M.D., Associate Professor of Surgery,
Department of Surgery, University Hospital of Magdeburg, Leipziger Strasse 44
39120 Magdeburg, Germany
H. Jaap Bonjer, M.D., Ph.D., Head ofLaparoscopic Surgery and
Acting Head of Endocrine Surgery, University Hospital Rotterdam
Dijkzigt Hospital, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
Ferdinand Kockerling, M.D., Professor of Surgery and Head Department of Surgery
and Center for Minimally Invasive Surgery, Hanover Hospital, Roesebeckstrasse 15
Silo ah, 30449 Hannover, Germany
ISBN 978-3-642-63117-7
Cataloging-in-Publication Data applied for
Die Deutsche Bibliothek - CIP-Einheitsaufnahme
Reymond, Marc A.: Port site and wound recurrences in cancer surgery : incidence -
pathogenesis - prevention / Marc A. Reymond ; H. J. Bonjer ; F. Kockerling. Foreword by
Alfred Cuschieri. Transl. from the German by A. Jack. - Berlin; Heidelberg ; New York;
Barcelona ; Hong Kong ; London ; Mailand ; Paris; Singapur ; Tokio : Springer, 2000
ISBN 978-3-642-63117-7 ISBN 978-3-642-57028-5 (eBook)
DOI 10.1007/978-3-642-57028-5
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Foreword
During the past 9 years, reports of 'port-site' deposits following laparoscopic
surgery for malignancy, especially laparoscopic resection of colonic cancer, have
cast a shadow on the wisdom of the laparoscopic approach in the surgical man-
agement in patients with cancer. Those reports of port-site deposits, some 90
cases reported in the literature up to 1999, have opened a 'can of worms' and
highlighted the scarcity of our knowledge on cancer cell migration from solid tu-
mors and the factors that underlie their successful implantation in surgical
wounds both in the presence and absence of a positive pressure pneumoperito-
neum. The jury is out even in relation to the effect of the healing surgical access
wound - do the biochemical and cellular repair processes and the associated
growth factors enhance or prevent implantation of exfoliated viable tumor cells?
Whatever the answer to this question, it is clear that tumor cells do implant in
healing surgical wounds and the key question is whether this is facilitated by lap-
aroscopic surgery with CO2 pneumoperitoneum compared to the traditional
surgical exposure. It is known that tumors shed malignant cells into the blood
stream, the peritoneal cavity and in the case of hollow organs, intraluminally.
Equally there is good evidence that surgical and instrumental manipulation of
tumors induce exfoliation of viable tumor cells.
The entire subject has been be-devilled by imponderable questions such as
'What is the nature of port- site/wound deposits in strict pathological terms?
What it the gold standard technique for detection and quantitation of exfoliated
tumor cells? What are the appropriate tumor models and animals for experimen-
tal investigation of this important problem, and how does the inevitable non-
specific immune depression caused by surgery impact on the optimal surgical
approach for resection of operable cancer?' The controversy on port-site/wound
deposits has also demonstrated, as never before, that it is easy to formulate a hy-
pothesis on presumed mechanisms of cancer cell migration and implantation
but much more difficult to prove what actually happens even with meticulous
and planned animal experimentation. Furthermore, in taking a clinical problem
such as port-site deposits to the laboratory, the appropriateness of the model
used is crucial to the valid extrapolation of the experimental results to the clini-
cal situation.
It is not surprising, therefore, that practicing surgeons have been confused by
the vast reported literature, at times seemingly contradictory, on clinical and ex-
perimental work on port-site tumor deposits since the early reports of such oc-
currences. A detailed reappraisal of the subject of port-site and wound deposits
in all their aspects based on the published clinical and experimental work was
necessary and long overdue. This is precisely what the editors of this monograph
'Port-Site and Wound Recurrence in Cancer' have done with considerable suc-
cess. The account is comprehensive, written by authors who have been involved
in research in the field and covers both the experimental work and the "clinical
VI Foreword
aspects of port -site/wound deposits. The monograph evaluates critically what is
known and equally what is conjectural at this stage of our knowledge on the sub-
ject. From a research standpoint, the limitations of the various tumor models
used and the useful conclusions that can be drawn are clearly and objectively
outlined in this book. There is much information and sound advice in this book
for both researchers and clinical surgeons.
In the final analysis 'port-site and wound deposits' have to be considered as
local recurrence and as with other instances of treatment failure, the surgeon
factor is important if not paramount. Rather than being a specific complication
oflaparoscopic surgery, port-site deposits have in part to be regarded as the af-
termath of poor surgical technique that is at least as much to blame as some
poorly understood biological mechanism. This to me is an important message
that is repeatedly stressed in this seminal monograph. Its success as a reference
manual on the subject is assured as the editors and their contributors have ad-
dressed this important subject in an objective fashion based on evidence and not
conjecture.
Prof Sir Alfred Cuschieri
Preface
Application of laparoscopic surgery to cancer has been associated with an in-
creased number of secondary tumors implanted into the abdominal wall, termed
"port-site recurrences". This complication reported for hundreds of patients in
the literature could discourage many surgeons to apply minimally invasive sur-
gery to cancer. However, in the meantime, the pathogenesis of port-site recur-
rences has been systematically addressed in basic and clinical research, and a
number of efficient preventive strategies have been developed. The large number
of published studies makes it difficult for the laparoscopic surgeon, the general
surgeon, the gastroenterologists, and the interested oncologist to get a synthetic
and critical overview over this novel field.
In this book we have united chapters from most of the groups which are active
worldwide in experimental and clinical research on port-site recurrences. The
problem of wound recurrence in open cancer surgery is also discussed in detail.
This should allow the reader to get an organized insight into the different patho-
genic mechanisms of port-site recurrences, notably as to where the cells from
which the secondary tumor arises come from, how they are dispersed, and how
local effects in the port-site wound can favor implantation. Moreover, the book
contains well illustrated guidelines to show preventive measures applicable by
any surgeon. These can reduce substantially the incidence of port-site recur-
rence, allowing a safer application of minimally invasive surgery in cancer.
Contents
1 Definition of Port-Site and Wound Recurrences in Cancer Surgery
A. Tannapfel, C. Wittekind
Introduction ................................................... .
Biological Basis of Port -Site Recurrences ........................... .
Location and Diagnosis of Port -Site Recurrences. . . . . . . . . . . . . . . . . . . .. 2
Time of Presentation of Port -Site Recurrences ....................... 3
Summary ...................................................... 4
References ..................................................... 4
2 A Case Report
1. Inan, M.A. Reymond . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 6
3 Abdominal Wall Recurrences in Open Surgery
L. Stocchi, H. Nelson
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8
Abdominal Wall Recurrence in Colorectal Cancer .................... 8
Autopsy Studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8
Second-Look Laparotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 9
Data from Prospective Adjuvant Therapy Trials . . . . . . . . . . . . . . . . . . . . .. 9
Abdominal Wall Recurrence After Malignancies Other than Colorectal
Cancer...... ....... ... .... ... .... ... ... .. .... .... ........ ... 9
Summary ...................................................... 11
References ..................................................... 11
4 Port-Site Recurrences in Laparoscopic Surgery
Ph. Wittich, H.I. Bonjer
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 12
Gynecological Malignancies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 12
Colorectal Cancer ............................................... 13
Gallbladder Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 16
Urological Malignancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 17
Diagnostic Laparoscopy .......................................... 17
References ..................................................... 18
5 Port-Site Recurrences in Thoracoscopic Surgery
R. Downey, M.A. Reymond
Dissemination After Fine Needle Puncture .......................... 21
Chest Wall Recurrence After Thoracotomy . . . . . . . . . . . . . . . . . . . . . . . . .. 22
Port-Site Recurrences After VATS .................................. 22
Preventive Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 23
References ..................................................... 24
X Contents
6 Port Site Recurrences in Colon and Rectal Cancers: Randomized Studies
T. Sonoda, J.w. Milsom
Prospective Data ............ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 26
Randomized Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 26
Influence of the Surgeon on the Incidence of Port -Site Recurrences .... 27
References .................................................... 27
7 Pathogenesis: Tumor Cell Lines and Application in Experimental
Animal Studies
J.w. Fleshman
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 29
Tumor Xenografts/Tissue Type ................................... 29
Tumor Cell Lines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 29
Mouse ...................................................... 29
Rat ......................................................... 31
Human ..................................................... 32
Experimental Protocols ......................................... 33
Documentation of Port -Site Recurrence Relationship to Laparoscopy 34
Investigation of the Mechanism of Cell Movement to and
Establishment of Tumor at Port -Sites . . . . . . . . . . . . . . . . . . . . . . . . .. 36
Factors Influencing Tumor Growth and Trocar Site Implantation .... 39
Prevention of Tumor Implantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 41
Conclusions ................................................... 42
References .................................................... 42
8 Pathogenesis: Transportation of Tumor Cells in Animal Studies
M.L. Texler, P.J. Hewett
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 44
Research to Date ............................................... 44
Small Animal Models .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 44
Large Animal Models ................... . . . . . . . . . . . . . . . . . . . . .. 44
Discussion .................................................... 48
Radiolabelled Cell Models in the Pig ............................ 49
Segmental Colonic Resection Studies. . . . . . . . . . . . . . . . . . . . . . . . . . .. 50
Conclusions ................................................... 50
References .................................................... 51
9 Pathogenesis: Local Effects in the Wound in Animal Studies
C.A. Jacobi, H.J. Bonjer
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 52
Experimental Tumor Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 52
Chimney Effect and Aerosolization of Tumor Cells ................ 52
Influence of Different Gases and Elevated Intraperitoneal Pressure. .. 54
Local Wound Conditions, Ischemia and Local Necrosis ............ 54
Local Effects on Mesothelial Cells and Peritoneal Structure ... . . . . .. 55
Changes ofIntra- and Extracellular pH and Calcium Levels in
Peritoneal Macrophages or Tumor Cells ........................ 55
Effects on Peritoneal Macrophages and Cytokine Production. . . . . . .. 56
Conclusions ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 57
References .................................................... 57
10 Pathogenesis: Immunological Aspects of Animal Studies
S. W. Lee, R.L. Whelan
Introduction ................................................... 60
Immune Suppression Following Open Surgery ...................... 60
Contents XI
Immune Function After Laparoscopic Procedures . . . . . . . . . . . . . . . . . .. 61
DTH Studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 61
Lymphocyte Proliferation Assays ............................... 62
Lymphocyte Subpopulation Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 63
Monocyte Function and Antigen Expression ..................... 63
Neutrophil Function .......................................... 64
Natural Killer Cell Activity ..................................... 64
Mechanism of Postoperative Immunosuppression . . . . . . . . . . . . . . . . . .. 65
Relationship Between Postoperative Immunosuppression and
Tumor Growth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 65
Immune Function and Port-site Tumors ........................... 66
Local Versus Systemic Immune Function ........................... 66
Conclusions ................................................... 67
References .................................................... 67
11 Pathogenesis: Free Viable Cancer Cells and Cancer Cell Liberation in
Clinical Studies
P. Buchmann, D. Christen, 1. Stocchi, H. Nelson
Introduction ................................................... 69
Predictive Value of Exfoliated Cells ................................ 69
Correlation with Local Recurrence and Survival. . . . . . . . . . . . . . . . . . . .. 71
References .................................................... 72
12 Pathogenesis: Transportation of Tumor Cells in Clinical Studies
M. Pross, K. Ridwelski, M.A. Reymond
Introduction ................................................... 74
Mechanisms Involved in the Transport of Tumor Cells ............... 74
Data from the Literature ......................................... 78
References .................................................... 79
13 Pathogenesis: Immunological Aspects of Clinical Studies
D. Mutter, M. Aprahamian
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 81
The Acute Phase Proteins. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 81
Interleukin-6 ................................................ 82
C-Reactive Protein ........................................... 83
The Other Cytokines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 84
Interleukin -1~ ............................................... 84
Tumor Necrosis Factor-u ...................................... 84
Other Cytokines ............................................. 85
The Immune Cells . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 85
Total White Blood Cell Changes ................................ 85
Leukocyte Subpopulation Changes .............................. 86
Changes in Immune Cell Functions ............................. 87
Other Host Defense Mechanisms ................................. 88
Histamine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 88
Production of Reactive Oxygen Species ... . . . . . . . . . . . . . . . . . . . . . .. 88
Nitric Oxide, Inducible NO Synthase and Peroxynitrite . . . . . . . . . . . .. 88
Conclusion .................................................... 89
References .................................................... 89
14 Mechanical Means For Prevention of Trocar Site Cancer Implantation
M.E. Franklin Jr., J.A. Diaz-E, J. Balli
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 91
Experimental Data ............................................. 91